Heavy Eye Syndrome

A 52-year-old woman with a history of high myopia for over 20 years presented with a one-year history of progressive inward deviation of the right eye and bilateral visual decline. On ophthalmologic evaluation, she exhibited esotropia, decreased abduction in the right eye, and high axial myopia bilaterally. There was no history of previous ocular trauma or strabismus surgery. Orbital MRI [Figure 1] reveals characteristic findings of heavy eye syndrome (HES), also known as myopic strabismus fixus. T2-weighted axial and coronal images showed elongation of the globes with superotemporal prolapse. The lateral rectus muscle was displaced inferiorly, while the superior rectus muscle was displaced nasally, increasing the angle between their centroids. These displacements produced mechanical restriction, explaining the observed esotropia and motility deficits. The LR–SR band was notably thinned, consistent with structural degeneration.[1]Figure 1: (a and b) Coronal T2-weighted images showing elongated globes and inferomedial displacement of extraocular muscles. (c and d) Measurement of dislocation angle between superior rectus and lateral rectus centroids: 136° (right eye), 123° (left eye). (e and f) Sagittal FLAIR, (g) axial T2-weighted, and (h and i) Coronal T2-fat-suppressed weighted MRI images reveal anteroposteriorly elongated globes with superotemporal globe prolapse and altered rectus paths. (j) Clinical photograph showing esotropia. (k). Clinical photograph of a patient in her young age without esotropia. FLAIR: Fluid attenuated inversion recoveryThese findings support the diagnosis of HES, which occurs due to mechanical displacement of the extraocular muscles secondary to extreme globe elongation. MRI plays a key role in differentiating HES from sagging eye syndrome (SES), which may have overlapping symptoms but lacks the superotemporal globe prolapse seen in HES. In SES, globe position remains central, and degeneration of the LR–SR band causes inferior displacement of the lateral rectus without medial shift of the superior rectus.[2] Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.